Nursing Fundamental Exam 2- Evolve questions

You are caring for a patient after surgery who underwent a liver resection. His prothrombin time (PT) or an activated partial thromboplastin time (APTT) is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin, and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions should you perform? Select all that apply. 1. Notify the surgeon. 2. Maintain intravenous (IV) fluid infusion and prepare to give volume replacement. 3. Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes. 4. Wean oxygen therapy. 5. Provide comfort through bathing.

1, 2, 3 A common early complication of surgery is bleeding. It is important to continue oxygen therapy and notify the surgeon. Signs of bleeding include hypotension; tachycardia; and cool, clammy, pale skin. Signs of bleeding may be visible, or the bleeding may be internal. Be prepared to administer fluid or blood as needed and frequently monitor vital signs to assess the patient's status.

The operating room (OR) and postanesthesia care unit (PACU) are high-risk environments for patients with a latex allergy. Which safety measures to prevent a latex reaction should the nurse implement? Select all that apply. 1. Screening patients about food allergies known to have cross-reactivity to latex 2. Having a latex allergy cart available at all times 3. Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive patient is identified 4. Scheduling the latex-sensitive patient for the last operative case of the day 5. Planning for the patient to be admitted to a private room after surgery

1, 2, 3 Identifying patients with potential cross-reactivity is important since they may be unaware of their latex sensitivity. Having all necessary equipment easily accessible to staff ensures that all items are available when needed. It is important for the operative team to be aware of the case so they can plan appropriate safeguards; scheduling the latex-sensitive patient for the first case means that latex dust from the previous day was removed overnight before the latex-sensitive patient's operation.

When using ice massage for pain relief, which of the following is correct? Select all that apply. 1. Apply ice using firm pressure over skin. 2. Apply ice for 5 minutes or until numbness occurs. 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage.

1, 2, 5 Apply the ice with firm pressure over the skin; then use a slow, steady circular massage. Apply ice for 5 minutes or until the patient feels numbness. It is acceptable to apply ice 2 to 5 times a day.

Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit should be done when a patient returns to the nursing unit. Which are appropriate components of a safe and effective hand-off? Select all that apply. 1. Vital signs, type of anesthesia provided, blood loss, and level of consciousness 2. Uninterrupted time to review the recent pertinent events and ask questions 3. Verification of the patient using one identifier and the type of surgery performed 4. Review of pertinent events occurring in the operating room (OR) while at the nurses' station 5. Location of patient's family members

1, 2, 5 A standardized approach or tool for hand-off communication helps providers provide accurate information about the care received in the operating room and the PACU before coming to the postoperative nursing unit. Proper identification of the patient requires using a standard of two identifiers and explaining the surgery performed and information about the type of anesthesia provided, blood loss, and level of consciousness. Allowing appropriate time for questions and communication free of distraction improves the quality of the hand-off. It must occur at the patient's bedside. Informing the nurse of the family's location ensures prompt notification.

A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? 1. Transcutaneous electrical nerve stimulation (TENS) 2. Administer naloxone (Narcan) 2 mg intravenously 3. Provide back massage 4. Reposition the patient 5. Withhold any pain medication and tell the patient that she is at risk for addiction

1, 3, 4 Nonpharmacological therapies may provide comfort for the patient. It is much too early to consider possible addiction. Naloxone is not appropriate at this time because the patient does not show signs of oversedation or respiratory depression.

A patient is admitted through the emergency department following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open-reduction internal fixation of bilateral femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this high-risk postsurgical patient include: Select all that apply. 1. Intermittent pneumatic compression stockings. 2. Vitamin K therapy. 3. Passive range-of-motion exercises every 4 hours. 4. Subcutaneous heparin or enoxaparin (Lovenox). 5. Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times higher than baseline.

1, 4 Combination therapy with mechanical and pharmacological prophylaxis is recommended for high-risk patients. Vitamin K therapy creates a higher risk for clotting, and the goal INR should not be 5 times higher than baseline.

The nurse is preparing to provide a patient with instructions for how to perform incentive spirometry. The patient will likely have incisional pain after returning from an elective colon resection. Which of the following steps for incentive spirometry is the patient likely to have the most difficulty performing? Select all that apply. 1. Assuming semi-Fowler's or high-Fowler's position 2. Setting the incentive spirometer device scale at the volume level to be attained 3. Placing the mouthpiece of the incentive spirometer so lips completely cover the mouthpiece 4. Inhaling slowly while maintaining constant flow through unit until it reaches goal volume 5. Breathing normally for a short period between each of the 10 breaths on incentive spirometry 6. Ending with two coughs after the end of 10 incentive spirometry breaths hourly

1, 4, 6 The patient will likely have pain after surgery, making it difficult to change positions and sit upright, take a full deep breath, and be able to cough. Splinting and administration of analgesics before the use of spirometry can increase the patient's ability to perform the exercise.

While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes: Select all that apply. 1. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. 2. Stopping acetaminophen when the pain becomes very severe. 3. Avoiding polypharmacy by limiting the use of medication to one agent at a time. 4. Avoiding total sedation, regardless of the severity of the pain. 5. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.

1, 5 Multimodal analgesia involves the use of a combination of drugs with at least two different mechanisms of action so pain control can be optimized. The use of acetaminophen, NSAIDs, gabapentin, and opioids represents a multimodal analgesic plan because each agent relies on a different mechanism of action to reduce pain, with the benefit of reducing the amount of opioid that is needed to control pain. This differs from polypharmacy because the combination of drugs is intentional and based on understanding of the action of each product on the pain pathway.

After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection. What should the nurse do next? Select all that apply. 1. Assess the injection site 2. Administer an oral medication for pain 3. Notify the patient's health care provider of assessment findings 4. Document assessment findings and related interventions in the patient's medical record 5. This is a normal finding so nothing needs to be done 6. Apply ice to the site for relief of burning pain

1,3, 4 If a patient describes localized pain, numbness, burning or tingling at an IM injection site, you need to suspect possible injury to nerve or tissues. Appropriate nursing actions include assessing the site, notifying the patient's health care provider, and documenting your findings

Which of the following are measures to reduce tissue damage from shear? 1. Use a transfer device, e.g. transfer board 2.Have head of bed elevated when transferring patient 3.Have head of bed flat when re positioning patients 4.Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1,3, 5 A transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed to be elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position will cause patient to slide down, causing shear.

Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? Select all that apply. 1. Only the patient should push the button. 2. Do not use the PCA until the pain is severe. 3. The PCA system can set limits to prevent overdoses from occurring. 4. Notify the nurse when the button is pushed. 5. Do not push the button to go to sleep.

1,3,5 The safety of PCA is based on the fact that it requires an awake patient to activate the button. The safety is compromised when someone else pushes the button for the patient. A limit on the number of doses per hour or 4-hour intervals may be set. Opioids (morphine PCA) are intended to provide analgesia; drowsiness is an undesirable potential side effect of opioids, and the PCA should only be used for analgesia.

A health care provider ordered enalapril (Vasotec) 2 mg IV push for a patient with hypertension. The pharmacy sent vials marked 1.25 mg enalapril/mL. How many mL does the nurse administer?

1.6 mL Use dimensional analysis to solve the problem.

A nurse is recovering a patient who received conscious sedation for cosmetic surgery. Which of the following is an advantage that conscious sedation has over general anesthesia? Select all that apply. 1. Loss of sensation at the surgical site 2. Reduction of fear and anxiety 3. Amnesia about procedure 4. Monitoring in phase I recovery 5. Close monitoring for airway patency

2, 3 Conscious sedation offers adequate sedation, reduction of fear and anxiety, amnesia, and relief of pain while maintaining airway patency and ventilation independently along with stable vital signs and rapid recovery. Loss of sensation at the surgical site is an effect of local anesthesia. These patients usually only go through phase II recovery.

Which of the following are signs and symptoms of a tension pneumothorax? (Select all that apply.) 1. Hypertension 2. Tachycardia 3. Distended neck veins 4. Hyptension

2, 3, 4 Distended neck veins, hypotension, and tachycardia are cardinal signs of a tension pneumothorax.

You are working in a health clinic on a college campus. You need to administer medroxyprogesterone acetate intramuscularly (IM) to a female patient for birth control. You look up this medication in a reference manual and determine that it is viscous and injections can be painful. On the basis of this information, you plan which of the following when administering this medication? 1. Inject the medication over 3 minutes to reduce pain associated with the injection 2. Administer the medication in the ventral gluteal site 3. Use the z-track method when administering the medication 4. Use the deltoid site for medication administration 5. Ask the patient questions about her major and which classes she is taking during the injection to provide distraction

2, 3, 5 When giving viscous medications intramuscularly, a patient typically experiences pain. Giving the medication in the ventral gluteal site using the z-track method and distracting the patient during medication administration will help to decrease pain associated with the medication.

Obesity places patients at an increased surgical risk because of which of the following factors? Select all that apply. 1. Risk for bleeding is increased. 2. Ventilatory capacity is reduced. 3. Fatty tissue has a poor blood supply. 4. Metabolic demands are increased. 5. Physical mobility is often impaired.

2,3,5 A decreased blood supply in adipose tissue slows the delivery of essential nutrients, antibodies, and enzymes needed for wound healing. A decreased ventilatory capacity allows for alveolar collapse, which can lead to pneumonia.

Your client is now on home oxygen and is nervous about the risk of fire. What tips can you give him for fire safety? (Select all that apply.) 1. Designate smoking rooms in his house for guests. 2. Test smoke detectors twice a year. 3. Store oxygen in a well-ventilated area. 4. Plan a fire evacuation route that includes an outside meeting place. 5. Plug concentrators into properly grounded outlets.

3, 4, 5 The client should store oxygen in a well-ventilated area, should use properly grounded outlets for plugging in the concentrator, and should plan a fire evacuation route. The client should post "No smoking" signs in and around the home; no one should smoke around oxygen. Guidelines recommend checking smoke detectors twice a month. (REF: p. 1029)

What is the correct sequence of steps when performing a wound irrigation? 1. Use slow continuous pressure to irrigate wound. 2. Attach angio catheter to syringe 3. Fill syringe with irrigation fluid 4. Place water proof bag near bed 5. Position angio catheter over wound A. 4, 3, 2, 5, 1 B. 3, 4, 2, 1, 5 C. 4, 2, 3, 5, 1 D. 2, 3, 4, 5, 1

4, 3, 2, 5, 1 Organized steps ensure a safe effective irrigation of the wound.

Which of the following is the correct order for insertion of an indwelling catheter in a female patient?1. Insert and advance catheter.2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus. 5. Drape the patient with the sterile square and fenestrated drapes. 6. When urine appears advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing. A. 7, 5, 2, 1, 4, 6, 3, 8, 9 B. 5, 7, 2, 4, 1, 6, 3, 8, 9 C. 5, 7, 1, 2, 4, 6, 3, 9, 8 D. 5, 7, 2, 1, 4, 3, 6, 8, 9

5, 7, 2, 4, 1, 6, 3, 8, 9 This is the correct order for insertion of an indwelling catheter in a female patient.

A child is taking albuterol through a pressurized metered-dose inhaler (pMDI) that contains a total of 64 puffs. The dose is 2 puffs every 6 hours. How many days will the pMDI last?

8 days The patient is taking 2 puffs every 6 hours which is 8 puffs a day. The inhaler has 64 puffs in it. To determine how many days the inhaler will last, divide the number of puffs by the number of doses per day that the patient takes; 64 puffs/8 puffs per day = 8 days.

People are able to express their values and preferences for care through a(n) ____________ when they can no longer speak for themselves.

advance directive

An injured football player asks how a cold pack makes his sports injury feel better. Which explanation by the nurse is most appropriate? A. "It decreases the blood flow, which reduces fluid accumulation that causes swelling." B. "It increases the release of endorphins, and this causes a decrease in pain receptor activity." C. "It overrides the pain sensation, causing a systemic anesthetic response." D. "It blocks the nerve impulses from the brain to the injured area."

A. "It decreases the blood flow, which reduces fluid accumulation that causes swelling." Clearly explaining exactly how the use of cold works is most helpful to the patient. Cold causes a local effect, not a systemic one. The other options contain incorrect information. (REF: p. 986)

If a patient is accidentally extubated, which of the following actions are appropriate? A. All of the above B. Assess patient for airway patency, spontaneous breathing, and vital signs. C. Assist respirations with bag-valve mask as needed. D. Remain with the patient.

A. All of the above All of the listed interventions are appropriate for unexpected extubation. The nurse should stay with the patient until assistance arrives to continually assess respiratory status and the need for any of the listed interventions. (REF: p. 644)

Which chest tube placement location promotes the removal of air? A. Apical (second or third intercostal space) B. None of the above C. Posterior (fifth or sixth intercostal space) D. Mediastinal

A. Apical (second or third intercostal space) The location of the chest tube indicates the type of drainage expected. Apical (second or third intercostal space) and anterior chest tube placement promote removal of air. Because air rises, these chest tubes are placed high, allowing evacuation of air from the intrapleural space and lung reexpansion. (REF: p. 656)

A pediatric nurse takes a medication to a 12-year-old female patient. The patient tells the nurse to take it away because she is not going to take it. What is the nurse's next action? A. Ask the patient's reason for refusal B. Consult with the patient's parents for advice C. Take the medication away and chart the patient's refusal D. Tell the patient that her health care provider knows what is best for her

A. Ask the patient's reason for refusal Whenever a patient refuses a medication, the first step is to talk with the patient to gather the patient's insights and possible reasons for not taking the medication.

What best describes measurement of post-void residual (PVR)? A. Bladder scan the patient immediately after voiding. B. Catheterize the patient 30 minutes after voiding. C. Bladder scan the patient when they report a strong urge to void. D. Catheterize the patient with a 16 Fr/10 mL catheter

A. Bladder scan the patient immediately after voiding. A PVR or post void residual is the measurement of urine in the bladder within 15 minutes of normal voiding. It would not be a true measurement of PVR if the bladder was full, or if after 30 minutes of voiding. A 16 Fr/10 mL catheter and would not be appropriate to use when catheterizing for PVR.

You are a new graduate nurse completing your orientation on a very busy intensive care unit. You cannot read a health care provider's order for one of your patient's medications. You have heard from more experienced nurses that this health care provider does not like to be called, and you know that another of the health care provider's patients is very unstable. What is the most appropriate next step for you to take? A. Call the health care provider to clarify the order B. Talk with your preceptor to help you interpret the order C. Refer to a medication manual before giving the medication D. Use your best judgment and critical thinking and administer the dose you think the health care provider ordered

A. Call the health care provider to clarify the order Whenever you are unable to read a patient's order, you must consult with the health care provider to clarify the order before giving the medication.

A health care provider writes the following order for an opioid-naive patient who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: A. Calls the health care provider and questions the order B. Applies the patch the third postoperative day C. Applies the patch as soon as the patient reports pain D. Places the patch as close to the hip dressing as possible

A. Calls the health care provider and questions the order Fentanyl patches are not indicated for acute pain. They are indicated for patients with chronic pain who are opioid tolerant.

The primary reason that family members should be included when a nurse teaches the patient preoperative exercises is so they can: A. Coach and encourage the patient after surgery. B. Demonstrate to the patient at home. C. Relieve the nurse by getting the patient to do the exercises every 2 hours. D. Practice with the patient while he or she is waiting to be taken to the operating room.

A. Coach and encourage the patient after surgery. Patients may need support from family to be motivated to return to their previous state of health. The family may also have better retention of preoperative teaching and will be with the patient and able to help him or her in recovery.

What is the removal of devitalized tissue from a wound called? A. Debridement B. Pressure reduction C. Negative pressure wound therapy D. Sanitization

A. Debridement Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

Upon visiting an elderly couple in their home, the nurse discovers that the wife is sharing her husband's antibiotic prescription. How should the nurse respond to this? A. Explain that taking someone else's medication is an unsafe practice. B. Offer to refill the prescription so the couple does not run out of medication. C. Report the incident to the local public health department. D. Ignore this information because it is not a matter of concern.

A. Explain that taking someone else's medication is an unsafe practice. Sharing medications can be common for older adults who are on a fixed income and are concerned about medication costs. This is unsafe, however, and no one should take a medication that was not prescribed for him/her, even if it is received from a family member. (REF: p. 1010)

An 86 year old woman is admitted to the unit with chills and a fever of 104 degrees F. What physiological process explains why she is at risk for dyspnea? A. Fever increases metabolic demands requiring increased oxygen need. B. Blood glucose stores are depleted and the cells do not have energy to use oxygen. C. Carbon dioxide production increases due to hyperventilation. D. Carbon dioxide production decreases due to hypoventilation.

A. Fever increases metabolic demands requiring increased oxygen need. When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles increasing the work of breathing.

A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? A. Patient's self-report B. Behaviors C. Surrogate (wife) report D. Vital sign changes

A. Patient's self-report Patient's self-report of pain. Sleep is not an indicator of pain intensity. Unless a patient is stimulated, it is difficult to distinguish sleep from sedation, which may occur as a side effect of the opioid. Patients in pain sometimes sleep from exhaustion.

The nurse contacts the prescriber and receives a STAT telephone order for a medication. What is the first thing the nurse should do after writing down the order? A. Read back the telephone order to the prescriber. B. Locate the prescriber and obtain a signature. C. Contact the pharmacy to have the medication sent to the nursing unit STAT. D. Prepare the medication for administration.

A. Read back the telephone order to the prescriber. After receiving a verbal or telephone order, the first thing the nurse should do is read back the order to verify what was said. Once the order has been verified, the nurse would prepare the medication or would contact the pharmacy in the event that the medication is not readily available. The prescriber would be expected to counter-sign the order within 24 hours. (REF: p. 481)

After a surgical patient has been given preoperative sedatives, which safety precaution should a nurse take? A. Reinforce to patient to remain in bed or on the stretcher B. Raise the side rails and keep the bed or stretcher in the high position C. Determine if patient has any allergies to latex D. Obtain informed consent immediately after sedative administration

A. Reinforce to patient to remain in bed or on the stretcher It is important for patient safety to inform patients who have been given sedatives of the importance of remaining in bed after preoperative sedatives are administered. It is inappropriate to have a bed or stretcher in the high position because of the increased fall risk and potential for injury. Obtain informed consent and assess allergies before sedative administration.

The nurse is performing a surgical scrub. Which action, if performed by the nurse, would require an intervention? A. The arms are rinsed from elbows to fingertips. B. The hands are dried from fingertips to elbows. C. The arms are divided mentally into thirds for scrubbing. D. Each finger and hand is visualized as having four sides.

A. The arms are rinsed from elbows to fingertips. The arms are rinsed from fingertips to elbows to prevent contamination of the scrubbed areas. The hands remain the cleanest part of the upper extremeties. If the nurse rinses from elbows to fingertips, water will roll down her arms carrying contaminants on to her hands. All other actions are part of correct surgical scrubbing. (REF: p. 913)

A postoperative patient currently is asleep. Therefore the nurse knows that: A. The sedative administered may have helped him sleep, but it is still necessary to assess pain. B. The intravenous (IV) pain medication given in recovery is relieving his pain effectively. C. Pain assessment is not necessary. D. The patient can be switched to the same amount of medication by the oral route.

A. The sedative administered may have helped him sleep, but it is still necessary to assess pain. A pain assessment is still needed because sleep in a postoperative patient cannot be used as an assessment of a patient's pain level. Sleep may result from sedating effects of medication, but analgesia may not be present. It is important to wake and assess the patient to ensure that the pain is controlled and the patient is not overly sedated from the medication (a sign of impending respiratory depression).

A "time-out" procedure is being conducted before the scheduled surgery begins. Which activity would the circulating nurse expect during this time? A. Verifying the correct operative site and side B. Assuring that all members of the surgical team have scrubbed C. Checking the numbers of sponges and sharps D. Placing ECG electrodes on the patient

A. Verifying the correct operative site and side The "time-out" procedure allows verification of correct operative site and side, patient identification, correct procedure to be performed, presence of specialized equipment and supplies, and correct patient position. (REF: p. 909)

When should discussions about home care safety take place? A. While the client is still in the acute care setting B. After the client has had a chance to settle back into his/her home C. On the first full day home with the client D. Only with caregivers so as not to upset the client

A. While the client is still in the acute care setting Quality care dictates that home safety be discussed before the client is discharged, in the acute care setting. Insurance companies often limit home care coverage; therefore, you must make the most of all opportunities to communicate with client and family, and must not wait until there is an incident. (REF: p. 994)

A nurse is providing postmortem care. Which action should be the priority? A. Properly identifying the body B. Locating the patient's clothing -- C and D C. Providing culturally and religiously sensitive care in body preparation D. Providing all postmortem care to protect the family of the deceased from having to see the body -- B and C

B and C The highest priority in postmortem care is to complete all activities with dignity and respect for cultural and religious beliefs. Proper identification of the body is essential to avoid situations of serious miscommunication. (REF: 386-387)

What statement made by a 24-year-old patient's mother indicates that she understands how to administer her son's eardrops? A. "To straighten his ear canal, I need to pull the outside part of his ear down and back." B. "I need to straighten his ear canal before administering the medication by pulling his ear upward and outward." C. "I need to put my son in a chair and make sure that he's sitting up with his head tilted back before I give him the eardrops." D. "After I'm done giving him his eardrops, I need to make sure that my son remains sitting straight up for at least 10 minutes."

B. "I need to straighten his ear canal before administering the medication by pulling his ear upward and outward." When administering medications to people 3 years of age and older, you need to pull the auricle upward and outward to straighten the ear canal when giving eardrops.

A patient is prescribed morphine patient-controlled analgesia (PCA). What is the correct order for administering PCA?1. Program computerized PCA pump to deliver prescribed medication dose and lockout interval.2. Check label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly.3. Administer loading dose of analgesia as prescribed.4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing.5. Identify patient using two identifiers.6. Insert and secure needleless adapter into injection port nearest patient. A. 1, 2, 4, 1, 6, 3 B. 2, 5, 1, 4, 6, 3 C. 1, 2, 5, 4, 6, 3 D. 2, 5, 4, 1, 3, 6

B. 2, 5, 1, 4, 6, 3 This is the appropriate order for administering PCA.

You have been given the following postoperative patients for care on your medical-surgical unit. On the basis of the information provided, which patient should you see first? A. A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 B. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of obstructive sleep apnea (OSA) (The pulse oximeter has been alarming and reading 85%.) C. A 36-year-old following bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotic D. A 48-year-old following total knee replacement who needs help repositioning in bed

B. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of obstructive sleep apnea (OSA) (The pulse oximeter has been alarming and reading 85%.) The patient with OSA has a risk of airway obstruction, which takes immediate precedence. She is symptomatic of oxygen desaturation.

A patient with a severe head injury has a severely elevated temperature. Which of the following is the best rationale for placing the patient on a hypothermia blanket? A. A hypothermia blanket in the automatic setting continually monitors the patient's temperature. B. A hypothermia blanket is believed to be neuroprotective and reduces or moderates negative neurologic outcomes. C. A hypothermia blanket reduces body temperature through conduction. D. A hypothermia blanket maintains the target temperature by raising or lowering the temperature of the circulating water.

B. A hypothermia blanket is believed to be neuroprotective and reduces or moderates negative neurologic outcomes. Although all of these answers regarding the hypothermia blanket are correct, the reason for its use in a patient with a head injury is to reduce or prevent any negative neurologic outcomes. (REF: p. 989)

Why is it important to assess a patient's understanding of a procedure? A. Encourages cooperation of the patient during and after the procedure B. All of the above C. Identifies teaching needs D. Minimizes risks to the patient

B. All of the above All of these outcomes are applicable to assessing patient knowledge of the procedure. If the patient understands what will happen to him during a procedure and why this is important for his health, he tends to cooperate during and after the procedure. If the patient understands the procedure and what he needs to do afterward to remain safe and free of complications, risks will be minimized. Also, by discussing the procedure with the patient, the nurse can identify teaching needs. (REF: p. 627)

A patient with pulmonary edema had BiPAP started 30 minutes ago. The nurse should inform the patient that he will undergo which diagnostic test shortly? A. Pulse oximetry reading B. Arterial blood gas C. Chest X ray D. Pulmonary Function test

B. Arterial blood gas When a patient is placed on noninvasive positive-pressure ventilation (BiPAP), it is necessary to evaluate the oxygenation and ventilation status of the patient. Although an arterial blood gas is an invasive procedure, it is important to know the patient's oxygen and carbon dioxide levels. Chest X-ray will provide information on fluid overload, and a pulmonary function test is inappropriate when a patient is acutely ill. A pulse oximetry reading would yield information on oxygenation. (REF: p. 602)

You are caring for a 65-year-old patient 2 days after surgery and helping him ambulate down the hallway. The surgeon has ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, the heart rate is 110. What should be your next action? A. Stop exercise immediately and have him sit in a nearby chair. B. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. C. Tell him that he needs to walk further to reach a heart rate of 120. D. Have him walk slower; he has reached his maximum.

B. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. The patient's maximum heart rate with exercise should be 220 - 65 = 155. He is still in a safe range. An assessment of how the patient feels is good practice. The patient can safely continue to walk.

In the event that a medication error occurs, the nurse should do the following first: A. Complete the institution's incident or occurrence report. B. Assess and examine the patient. C. Contact the manager or supervisor of the area where the error occurred. D. Contact the prescriber to inform him/her of the error.

B. Assess and examine the patient. The nurse should always assess and examine the patient immediately after an error has occurred. Once the patient's safety and well-being have been assessed, the nurse should contact the prescriber. Completing the occurrence or incident report and notifying the manager or supervisor would take place next. (REF: p. 489)

Which of the following signs or symptoms in an opioid-naive patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A. Oxygen saturation of 95% B. Difficulty arousing the patient C. Respiratory rate of 10 breaths/min D. Pain intensity rating of 5 on a scale of 0 to 10

B. Difficulty arousing the patient Sedation is a concern because it may indicate that the patient is experiencing opioid-related side effects. Advancing sedation may indicate that the patient may progress to respiratory depression.

After seeing a patient, the health care provider starts to give a nursing student a verbal order for a new medication. The nursing student first needs to: A. Follow ISMP guidelines for safe medication abbreviations. B. Explain to the health care provider that the order needs to be given to a registered nurse. C. Write down the order on the patient's order sheet and read it back to the health care provider. D. Ensure that the six rights of medication administration are followed when giving the medication.

B. Explain to the health care provider that the order needs to be given to a registered nurse. Nursing students cannot take medication orders.

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? A. Antibiotics B. Frequent change of position C. Oxygen humidification D. Chest physiotherapy

B. Frequent change of position Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.

The circulating nurse is assisting the surgical team into their gowns. Which action by the circulating nurse would be expected? A. Documenting in the patient's record the use of sterile technique B. Holding the sterile paper tab attached to the sterile gown tie C. Helping the surgeon pull his gown on, exposing his hands D. Handing the sterile gloves individually to the surgeon

B. Holding the sterile paper tab attached to the sterile gown tie The circulating nurse, who is not sterile, will hold the sterile paper tab attached to the tie of the sterile gown. The surgical team member who is wearing the gown extends this part to the circulating nurse, who then removes it, exposing the other sterile tie, which the surgical team member ties after turning around to bring it around the body. (REF: p. 917)

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? A. Binder B. Ice bag C. Elastic bandage D. Absorptive dressing

B. Ice bag An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.

A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient has been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for arthritic pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? A. No action is required by the nurse because the order is appropriate. B. Request to have the order changed to around the clock (ATC) for the first 48 hours. C. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. D. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.

B. Request to have the order changed to around the clock (ATC) for the first 48 hours. The patient can be expected to have acute pain related to the G-tube insertion; in addition, she has a history of chronic pain. Her pain should be treated with ATC medication to match the timing of her pain.

A nursing student is administering ampicillin PO. The expiration date on the medication wrapper was yesterday. What is the appropriate action for the nursing student to take next? A. Ask the nursing professor for advice B. Return the medication to pharmacy and get another tablet C. Call the health care provider after discussing this situation with the charge nurse D. Administer the medication since medications are good for 30 days after their expiration date

B. Return the medication to pharmacy and get another tablet The nurse needs to return the medication to the pharmacy and get a tablet that is not expired because expired medications should not be administered.

What does the Braden Scale evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk factors that place the patient at risk for skin breakdown C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk for poor healing

B. Risk factors that place the patient at risk for skin breakdown The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? A. Recommend she be evaluated for an OAB medication. B. Start a scheduled toileting program. C. Recommend she be evaluated for an indwelling catheter. D. Start a bladder retraining program

B. Start a scheduled toileting program. The first nursing intervention for any patient with incontinence, who is able to toilet, is to assist them with toilet access. This patient is not cognitively intact so a bladder retraining program is not appropriate for her. It is not clear in this case that she has OAB and a catheter is never a good solution for incontinence.

A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question? A. The drug B. The time interval C. The dose D. The route

B. The time interval Long-acting or sustained-release opioids are dosed on a scheduled basis, not prn, to provide a base of continuous opioid analgesia.

A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39° C (102° F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. The nurse immediately notifies the surgeon of the patient's vital signs because: A. He or she needs to get the patient into the operating room (OR) quickly to start the surgery because of the low BP. B. The surgery may need to be delayed to recheck the patient's WBC count and investigate the source of fever before surgery. C. The nurse anticipates the need for a fluid bolus to increase the patient's BP. D. The nurse anticipates an order for a sedative to help calm the patient and decrease the heart rate.

B. the surgery may need to be delayed to recheck the patient's WBC count and investigate the source of fever before surgery. The patient has a fever, elevated WBC count, tachycardia, and hypotension, which are all signs of a potential infection. It may be necessary to delay the surgery until the source of the fever is treated

You have identified three nursing diagnoses for a patient who is showing decreased interest in food, insomnia, and hopelessness upon hearing that no treatment options are available for her disease. What general approach will you take in prioritizing the nursing diagnoses? A. Address the nursing diagnosis that is most related to the medical diagnosis. -- A and B B. Use family members and physician orders as primary resources for prioritizing your actions. C. Address the problem that you believe is the underlying cause of the other diagnoses. -- C and D D. Determine what the patient believes is the most distressing symptom, and first address that diagnosis.

C and D Prioritize care by addressing the patient's most distressing problem and by identifying symptoms that might be causing some of the other issues, so that the patient may attain greater overall symptom relief. (REF: 376)

A patient who has a serious, life-limiting chronic illness wants to continue to engage in self-care and live as normally as possible. Which of the following nursing responses reflects a helpful understanding of the importance of patient self-care at the end of life? A. "Learning to accept that you can't do some activities anymore will bring you peace." B. "Spend more of your time resting or reading to conserve your energy." C. "What activities are most important for you, and how can you continue to perform them?" D. "People in your life want to help you with things, so allow them to do what they want to do for you."

C. "What activities are most important for you, and how can you continue to perform them?" Patient-centered care includes helping patients identify ways in which they can continue their self-care and maintain normalcy in life. They should be encouraged to continue important activities. The other three responses show the nurse giving advice instead of eliciting patient preference. (REF: 376)

What is the correct sequence for suctioning a patient?1. Open kit and basin.2. Apply gloves.3. Lubricate catheter.4. Verify functioning of suction device and pressure.5. Connect suctioning tubing to suction catheter.6. Increase supplemental oxygen.7. Reapply oxygen.8. Suction airway. A. 6, 4, 3, 1, 2, 5, 8, 7 B. 4, 6, 1, 2, 3, 8, 5, 7 C. 4, 6, 1, 3, 2, 5, 8, 7 D. 6, 4, 1, 3, 2, 5, 7, 8

C. 4, 6, 1, 3, 2, 5, 8, 7 These steps allow for smooth completion of procedure while helping to maintain patient's level of oxygenation.

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A. Coughing up thick sputum only occasionally B. Coughing up thin, watery sputum after nebulization C. Decreased ability to clear airway through couching D. Lung sounds clear only after coughing

C. Decreased ability to clear airway through couching Impaired ability to cough up mucous due to weakness or very thick secretions indicates a need for suctioning.

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? A. Do you leak urine when you cough or sneeze? B. Do you need help getting to the toilet? C. Do you dribble urine constantly? D. Does it burn when you pass your urine?

C. Do you dribble urine constantly? Incontinence characterized by constant dribbling of urine is associated with incontinence associated with urinary retention. . The other options point to stress incontinence, functional incontinence or a UTI.

A patient has a nasogastric tube after abdominal surgery. Which action by the nurse best maintains the patency of the air vent? A. Keeping the blue pigtail above the patient's stomach B. Irrigating the blue pigtail with 10 to 20 mL of normal saline C. Irrigating the blue pigtail with 10 mL of air D. Measuring the patient's nasogastric output twice each shift

C. Irrigating the blue pigtail with 10 mL of air Irrigating the air vent with air, whether with 10 mL using a catheter-tipped syringe or with a pop of air from an Asepto syringe, will maintain the patency of the air vent, also known as the blue pigtail. (REF: p. 862)

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? A. Pale yellow urine B. Slightly cloudy urine C. Light pink urine D. Dark amber urine

C. Light pink urine Light pink urine indicates the presence of blood in the urine, which is never a normal finding. First voided urine can normally be slightly cloudy and darker in color. Pale yellow urine indicates normal finding.

During a training session, the nurse is reviewing where the pads for the automated external defibrillator (AED) should be positioned. Training would have been successful if which pad placement was demonstrated by the attendees? A. One pad is on the upper left sternal border and one pad is to the right of the apex of the heart. B. One pad is on the upper left sternal border and one is lateral to the left nipple several inches below the axilla. C. One pad is on the upper right sternal border and one is lateral to the left nipple several inches below the axilla. D. One pad is on the upper right sternal border and one pad is on the right flank.

C. One pad is on the upper right sternal border and one is lateral to the left nipple several inches below the axilla.

A nurse admits a 72-year-old patient with a medical history of hypertension, heart failure, renal failure, and depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes that the patient has three health care providers who have ordered a total of 13 medications. What is the most appropriate action for the nurse to take next? A. Give the medications after identifying the patient using two patient identifiers B. Provide medication education to the patient to help with adherence to the medical plan C. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications D. Set up a medication schedule for the patient that is least disruptive to the expected treatment schedule in the hospital

C. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications This patient most likely is experiencing polypharmacy. To minimize risks associated with polypharmacy, frequent communication among health care providers is essential to make sure that the patients' medication regimen is as simple as possible.

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? A. Opioid antagonists B. Antiemetics C. Stool softeners D. Muscle relaxants

C. Stool softeners Constipation is a common opioid-related side effect, and patients do not become tolerant to it.

The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? A. The patient's level of pain B. The potential for addiction C. The amount of daily acetaminophen D. The risk for gastrointestinal bleeding

C. The amount of daily acetaminophen The Food and Drug Administration (FDA) recommends a maximum daily dose of 4 g of acetaminophen, and many authorities believe that the maximum daily dose should be lower (3000 to 3200 mg/day) in the outpatient setting to reduce the risk of hepatotoxicity.

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? A. Category/Stage II B. Category/Stage IV C. Unstageable D. Suspected deep tissue damage

C. Unstageable To determine the category/stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for medication administration for this child? A. A medication cup B. A teaspoon C. A 5-mL syringe D. An oral-dosing syringe

D. An oral-dosing syringe Syringes for oral dosing are adapted for accurate administration of medication to pediatric patients. They do not have a syringe or needle cap and cannot accidentally be used to administer parenteral medications.

The nurse is administering an intravenous (IV) push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of intravenous (IV) tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of intravenous (IV) line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port. 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude intravenous (IV) line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return. A. 2, 5, 4, 1, 3, 6 B. 2, 5, 6, 4, 1, 3 C. 5, 4, 2, 6, 1, 3 D. 2, 5, 4, 6, 1, 3

D. 2, 5, 4, 6, 1, 3 This is the appropriate order for a nurse to administer an intravenous (IV) push medication to a patient who has a compatible IV fluid running through intravenous tubing.

A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority? A. Complete an occurrence report. B. Notify the health care provider. C. Inform the charge nurse of the error. D. Assess the patient for adverse effects.

D. Assess the patient for adverse effects. Whenever a medication error occurs, the first action of the nurse is to assess the patient.

The home care nurse is scheduled to visit a Mexican-American client who is newly diagnosed with cardiovascular disease for the first time. The nurse can expect the family to: A. Cancel the scheduled home care visit. B. Ask the nurse to place the client in a long-term care facility. C. Refuse to participate in care of the client. D. Assume care of the client themselves.

D. Assume care of the client themselves. Mexican-American families prefer to assume responsibility for the care of family members. The home care nurse needs to recognize this preference and must work with the client and family in planning and implementing care. (REF: p. 995)

Because an older adult is at increased risk for respiratory complications after surgery, the nurse should: A. Withhold pain medications and ambulate the patient every 2 hours. B. Monitor fluid and electrolyte status every shift and vital signs with temperature every 4 hours. C. Orient the patient to the surrounding environment frequently and ambulate him or her every 2 hours. D. Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control.

D. Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control. Adequate pain control is important to allow participation in postoperative exercises such as turning, deep coughing, and deep breathing to prevent respiratory complications.

The scrub nurse sees a nurse who is gowned and gloved brushing up against something unsterile. The nurse disputes that she has been contaminated. What is the appropriate action by the scrub nurse? A. Allow the nurse to continue with assigned surgical responsibilities. B. Tell the director of the operating room about the incident. C. Change the activities the nurse would perform during the procedure. D. Insist that the nurse re-scrub and re-gown before continuing.

D. Insist that the nurse re-scrub and re-gown before continuing. When in doubt, consider yourself contaminated. If someone else thinks you have become contaminated, do not argue. Re-scrub, then re-gown for safety. (REF: p. 909)

You are a nurse in the postanesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated? A. Infection: Notify surgeon and anticipate administration of antibiotics. B. Pneumonia: Listen to breath sounds, notify surgeon, and anticipate order for chest radiography. C. Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives. D. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently.

D. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently. Malignant hyperthermia is a life-threatening complication of general anesthesia. It is a severe hypermetabolic condition that causes rigidity of skeletal muscles caused by an increase in intracellular calcium ion concentration and leads to hypercarbia, tachypnea, and tachycardia. An elevated temperature is a late sign, and an increase in the respiratory rate to eliminate carbon dioxide is one of the first signs. Dantrolene sodium (Dantrium) is a skeletal muscle relaxant used to treat this complication.

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: A. Opioid toxicity. B. Opioid tolerance. C. Opioid addiction. D. Opioid withdrawal.

D. Opioid withdrawal. The common symptoms of opioid withdrawal that are associated with physical dependence may develop when an opioid is withdrawn rapidly. Symptoms include shaking chills, abdominal cramps, and joint pain.

A dying patient wants to have an open casket at his funeral. After the patient's death, which action by the nurse is most critical in maintaining his appearance? A. Tie his hand together to prevent them from moving when the body is transported. B. Tape his eyelids down so the eyeballs maintain their moisture and shape. C. Remove all indwelling devices and bandages before bathing the patient. D. Place him supine with the head of the bed elevated 30 degrees.

D. Place him supine with the head of the bed elevated 30 degrees. Elevating the head prevents pooling of blood in the facial area and preserves a natural facial color. Tying the hands could leave abrasions or cuts in the skin. (REF: 385-386)

In the postanesthesia care unit (PACU) the nurse notes that the patient is having difficulty breathing and suspects an upper-airway obstruction. The nurse would first: A. Suction the pharynx and bronchial tree. B. Give oxygen through a mask at 4 L/min. C. Ask the patient to use an incentive spirometer. D. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward.

D. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward. Weak pharyngeal/laryngeal muscle tone from anesthetics can occur. Positional change helps to move the tongue forward to open the airway. The immediate intervention should be to open the airway. Suctioning the bronchial tree or providing oxygen does not alleviate an upper-airway obstruction.

The scrub nurse is in surgical garb and is standing with his arms crossed in front of his chest with his hands in his axillary region, and surgery is about to start. What is the correct action for this nurse to take? A. Ask the surgeon what he should do. B. See whether anyone notices his action. C. Continue with the procedure as scheduled. D. Rescrub, re-gown, and re-glove.

D. Rescrub, re-gown, and re-glove. The hands should not be placed in the axillary region because of the chance of perspiration seeping through the surgical gown. The nurse should excuse himself without anyone having to tell him what to do and should remove his gown and gloves, re-scrub, and put on a new surgical gown and gloves. (REF: p. 911)

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? A. TENS works by causing distraction. B. TENS therapy does not require a health care provider's order. C. TENS requires an electrical source for use. D. TENS electrodes are applied near or directly on the site of pain.

D. TENS electrodes are applied near or directly on the site of pain. TENS units act on both the central and peripheral nervous systems. The peripheral effect occurs through activation of the neuroreceptors at or near the source of pain; therefore the electrodes should be placed near the site.

A nursing student is administering medications to a patient through a gastric tube (G-tube). Which of the following actions taken by the nursing student requires the nursing instructor to intervene? A. The nursing student places all the patient's medications in different medicine cups. B. The nursing student evaluates each medication and holds the tube feeding before administering a medication that needs to be administered on an empty stomach. C. The nursing student flushes the tube with 30 mL of water between each medication. D. The nursing student crushes a nifedipine extended-release tablet and mixes it with water before administering it.

D. The nursing student crushes a nifedipine extended-release tablet and mixes it with water before administering it. Extended-release tablets should not be crushed; the nursing student needs to question this order and investigate alternative medications while the patient is receiving medications through the gastric tube.

What is the goal of computerized physician order entry (CPOE)? A. To increase the number of medication orders B. To decrease the number of medication orders C. To cause less inconvenience for prescribers D. To prevent serious medication errors

D. To prevent serious medication errors CPOE systems may significantly reduce medication errors, by as much as 55% to 83%. The use of CPOEs does not increase or decrease the number of medication orders and was not instituted to cause less inconvenience for prescribers. (REF: p. 478)

Normal wound healing requires a physiologic wound environment that includes which of the following? (Select all that apply.) Select all that apply. 1. Temperature control 2. Control of bacterial burden 3. Adequate moisture 4. Tissue eschar

1, 2, 3 A healthy physiologic wound environment includes adequate moisture, control of temperature, pH, and bacterial burden to promote healing. Eschar or necrotic tissue forms in deep infected wounds. (REF: p. 942)

When a patient self-administers a vaginal suppository, which behavior would require further teaching? (Select all that apply) 1. The patient lies on her left side. 2. The patient inserts the suppository 10 cm (4 inches) into the vaginal canal. 3. The patient uses her dominant hand to insert the suppository along the posterior wall of the vaginal canal. 4. The patient voids before insertion.

1, 2 Answer "B" describes the correct position for a rectal suppository, and answer "D" explains the correct distance for insertion of a rectal suppository. (REF: pp. 531-532)

In creating a culture of home care safety, the nurse will consider which of the following? (Select all that apply.) Select all that apply. 1. Role of caregivers in the family 2. Age of the client 3. Surrounding neighborhoods 4. Concern for the health care provider's safety 5. Physical layout of the home

1, 2, 3, 4, 5 Creating a culture of home care safety takes into account the client and family caregivers, but also the health care provider. All parties need to feel secure and safe. In addition, the physical environment within and outside the home is of concern, and, in relation to culture, the role of the caregiver must be considered. In some cultures, the direct caregiver is a family member, and the family may not look favorably on an outsider, such as the health care provider. (REF: p. 994-995)

What are the three main expected outcomes after a chest tube has been inserted? 1. Breath sounds are noted in all lobes. 2. The patient's vital signs and oxygen saturation are within normal limits. 3. The patient complains of chest discomfort. 4. The patient's breathing is nonlabored.

1, 2, 4 Expected outcomes of chest tube insertion include breath sounds noted in all lobes, vital signs and oxygen saturation within normal limits, and breathing that is nonlabored. Complaints of chest discomfort are not expected. The patient may need analgesia for this complaint or may have to undergo further assessment by the health care provider. (REF: p. 663)

A mother calls you in a panic because she has dropped a mercury thermometer and needs instructions on how to clean the mercury spill. What information do your instructions include? (Select all that apply.) 1. Place mercury beads on a damp paper towel and place the towel in a zip-loc bag. 2. Use shaving cream to dot the area of mercury beads. 3. Close all windows in the room of the spill. 4. Put on rubber or nitrile gloves. 4. Enlist the help of her oldest child, a 10-year-old, to assist her in cleaning.

1, 2, 4 Putting on protective gloves, using shaving cream to stabilize the mercury beads, and capturing the beads on a paper towel, which is then sealed in a zip-loc bag, is the correct procedure. Never enlist a child to help with mercury cleanup; it is too dangerous. Instruct the mother to close off the rest of the house from the room with the spill, but the room itself where the spill occurred needs increased ventilation—open the windows and turn on a fan. (REF: p. 1019)

The nurse is caring for a patient who exhibits labored breathing, using accessory muscles, and is coughing up pink frothy sputum. The patient has bilateral lung bases and diminished breath sounds. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? Select all that apply. 1. SpO2 levels 2. Amount, color and consistency of sputum production 3. Fluid status 4. Change in respiratory rate and pattern 5. Pain in lower leg

1, 2, 4 These are key respiratory assessments that provide data on patient's worsening respiratory status. While fluid status does impact respiratory status, it is not a priority assessment at this time. Pain in lower leg is assessed later.

A patient has a moist compress with a water flow pad (aquathermia) applied over the compress for 20 minutes. Which of the following are appropriate steps to take when using this equipment? (Select all that apply.) 1. When needed, fill the reservoir with distilled water. 2. Place plastic wrap between the compress and the device. 3. Apply towel or bath blanket over the device. 4. Apply directly over the compress.

1, 3 Distilled water in the reservoir maintains a constant preset temperature of the device. Placing a bath blanket or towel around the devices reduces the risk of injury to underlying skin from burns. Plastic wrap is not used because it conducts heat and increases the risk of injury. Applying the water flow device directly over the compress also increases the risk of burn injury to adjacent skin and tissues. (REF: p. 981)

When is an application of a warm compress to an ankle muscle sprain indicated? 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure ulcers 5. To immobilize area

1, 3 Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

What should the nurse teach a young woman with a history of urinary tract infections about UTI prevention? 1. Keep the bowels regular. 2. Limit water intake to 1-2 glasses a day 3. Wear cotton underwear 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

1, 3, 4 All are interventions that lead to healthy bladder habits. Adequate hydration will ensure that the bladder is regularly flushed out and will help prevent a UTI. Pelvic muscle exercises promote pelvic health but not necessarily prevent UTI.

20 days are at increased risk for health care-associated infection (HAI). Which of the following nursing interventions are appropriate for decreasing this risk? (Select all that apply.) 1. Encouraging deep breathing exercises 2. Refraining from use of analgesia because this would depress respirations 3. Providing patient education regarding these practices 4. Assisting patient with early mobility

1, 3, 4 Researchers have found that patients who have chest tubes longer than 20 days are at six times greater risk of developing an HAI than those who have chest tubes for a period shorter than 20 days. On the basis of this information, nurses should be vigilant regarding the need for a chest tube, should encourage deep breathing exercises and early mobility, as well as use of appropriate analgesia to promote activity, and should provide patient education regarding these practices. Patients should be given appropriate analgesia so they will be able to increase their mobility and to cough and deep breathe more effectively. (REF: p. 658)

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? 1. Notify the surgeon 2. Allow the area to be exposed to air until all drainage has stopped 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels and immediately. 5. Cover the area with sterile gauze and apply an abdominal binder

1, 4 If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented prior to the test? 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Explain that the test includes instrumentation of the urinary tract.

1, 4 An intravenous pyelogram (IVP) involves intravenous injection of an iodine based contrast media. Patients that have had a previous hypersensitivity reaction to contrast media in the past are at high risk for another reaction. Informed consent is required. There is no need for a full bladder such as with a pelvic ultrasound or to save any urine for testing. There is no instrumentation of the urinary tract such as with a cystoscopy.

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply). Select all that apply. 1. Sharp pleuritic pain that worsens on inspiration 2. Crackles over lung bases of affected lung 3. Tracheal deviation toward the affected lung 4. Worsening dyspnea 5. Absent lung sounds to auscultation on affected side

1, 4, 5 When the lung collapses, as with a pneumothorax, the thoracic space fills with air, which irritates the parietal pleura causing inspiratory pain. Because of the collapsed lung there is reduced gas exchange in the affected area, reduced oxygenation and dyspnea result. When an area of the lung collapses, breath sounds over affected area are absent.

Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? 1. Frequent position changes. 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment

1, 4, 6 Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin care and moisture barriers must also be used with frequent position changes to assist in reducing the risk for pressure ulcers.

Which of the following CPT maneuvers can be delegated? (Select all that apply.) 1. Acapella device 2. Postural drainage 3. Shaking 4. Vibration

1,2,3,4 All of these maneuvers may be delegated to assistive personnel. However, the nurse is responsible for performing respiratory assessment, reviewing the chest X-ray when appropriate, and determining that the patient is stable for the procedure. (REF: p. 615)

Which of the following are necessary to prepare the patient for postural drainage? (Select all that apply.) 1. Explain the procedure and positioning techniques. 2. Schedule treatment 1 to 2 hours after meals. 3. Coordinate treatments with other respiratory or medical therapies. 4. Encourage fluid intake of 1500 to 2000 mL.

1,2,3,4 Coordinating therapy around a patient's meals and activities reduces the risks for aspiration, conflict with other therapies, and fatigue. In addition, adequate fluid intake helps to liquefy secretions so the patient can easily clear them. As always, informing patients of any therapy promotes cooperation and decreases anxiety. (REF: p. 617)

Which nursing interventions should the nurse implement when removing an indwelling urinary catheter in an adult patient? 1. Attach a 3 mL syringe to the inflation port 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary 4. Pull catheter quickly 5. Clamp the catheter prior to removal.

2, 3 By allowing the balloon to drain by gravity the development of creases or ridges in the balloon may be avoided and thus minimize trauma to the urethra during withdrawal. All patients who have a catheter removed should have their voiding monitored. The best way to do this is with a voiding record or bladder diary. The size syringe used to deflate the balloon is dictated by the size of the balloon. In the adult patient balloon sizes are either 10 mLs or 30 mLs. Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping catheters prior to removal.

Which of the following skills can be delegated to nursing assistive personnel (NAP)? Select all that apply. 1. Nasotracheal suctioning 2. Oropharyngeal suctioning of a stable patient 3. Suctioning a new artificial airway 4. Permanent tracheostomy tube suctioning 5. Care of an endotracheal tube (ETT)

2, 4 Oropharyngeal suctioning of a stable patient and permanent tracheostomy tube suctioning may be safely delegated to a NAP. The other skills require nursing assessment and clinical decision making as the skill progresses.

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? 1. Collection of wound drainage 2. Provides support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2, 4 A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

Several factors affect the volume and consistency of endotracheal secretions. Which of the following causes an increase in the amount and thickness of secretions? (Select all that apply.) 1. Humidification 2. Respiratory rate 3. Fluid intake 4. Infection

4. Infection Patients with respiratory infection, such as pneumonia, are prone to increased secretions that are thicker and sometimes are more difficult to expectorate. Fluid intake increases the amount of secretions but will thin them. Humidity loosens secretions, facilitating airway suctioning when the patient cannot clear secretions effectively. Rate of respirations will not effect the amount or viscosity of secretions. (REF: p. 631)

An older adult with diarrhea, dehydration, and a history of cardiac problems has been admitted. Which laboratory results would be of prime importance for the nurse to monitor? A. Calcium and potassium B. Blood urea nitrogen (BUN) and creatinine C. Sodium and protein (albumin) D. Phosphorus and magnesium

A. Calcium and potassium Electrolyte imbalances, especially those involving potassium and calcium, can precipitate cardiopulmonary arrest. Dehydration can lead to electrolyte imbalance. (REF: p. 676)

The nurse is preparing to verify the placement of a patient's nasogastric tube. Which method of placement verification by the nurse would best indicate that the end of the tube is in the stomach? A. Checking the pH of the aspirated gastric contents B. Listening for the return of the patient's bowel sounds C. Auscultating the stomach while air is injected into the nasogastric tube D. Obtaining gastric fluid in the tube when aspirating with a syringe

A. Checking the pH of the aspirated gastric contents The best method, of those listed, is to check the pH of the aspirated gastric contents to ensure that gastric contents are in the tube. Gastric aspirates usually have a pH of 4 or less. (REF: p. 860)

Use of noninvasive positive-pressure ventilation (CPAP or BiPAP) has the potential to cause carbon dioxide retention in selected patients. Patients with which of the following underlying diagnoses are at greatest risk for carbon dioxide retention? A. Chronic obstructive pulmonary disease B. Pulmonary edema C. Pulmonary fibrosis D. Heart failure

A. Chronic obstructive pulmonary disease Patients diagnosed with COPD who have ventilatory failure are at risk to retain carbon dioxide. Patients with heart failure, pulmonary fibrosis, or pulmonary edema are at greatest risk for oxygen failure. (REF: p. 602)

An older patient with limited mobility and strength is recovering from hip surgery and needs to use the bedpan. Which action by the nurse would best facilitate this procedure? A. Obtaining the assistance of at least two other staff members B. Encouraging the patient to pull up on the overhead trapeze C. Lightly sprinkling a small amount of powder on the bedpan D. Rolling the patient slightly on his side for better positioning

A. Obtaining the assistance of at least two other staff members Because this patient is unable to safely and predictably help with moving, obtaining extra staff members would provide the safest method. Additional people may still be needed even if the other actions are taken. (REF: p. 845)

The nurse goes to assess a new patient and finds him short of breath with a rate of 32 and lying supine in bed. What is the priority nursing action? A. Raise the head of the bed to 60 degrees or higher. B. Get his oxygen saturation with a pulse oximeter. C. Take his blood pressure and respiratory rate. D. Notify the health care provider of his shortness of breath.

A. Raise the head of the bed to 60 degrees or higher. Raising the head of the bed will bring the diaphragm down and allow for better chest expansion thus improving oxygenation.

Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A. Record the amount and continue to monitor drainage. B. Notify the physician. C. Strip the chest tube starting at the chest D. Increase the suction by 10 mm Hg

A. Record the amount and continue to monitor drainage. Dark red drainage after surgery (50-200 ml per hour in first 3 hours) is expected but be aware of sudden increases greater than 100 ml per hour after the first three hours especially if becomes bright red in color.

The nurse is caring for a patient who has an order for an acetaminophen (Tylenol) rectal suppository. Which finding contraindicates the use of a rectal suppository? A. Rectal bleeding B. Presence of a fever C. Rectal hemorrhoids D. Constipation

A. Rectal bleeding Rectal suppositories are contraindicated in patients with rectal, bowel, or prostate surgery or with active rectal bleeding. (REF: p. 533)

A patient developed a 2-cm stage I pressure ulcer over the sacrum. A transparent dressing has been in place for 2 days. The nurse on the evening shift notices that the skin under the dressing appears broken. The patient complains of tenderness when the nurse palpates the skin. The nurse also notices drainage under the transparent film. What action should the nurse take in this situation? A. Remove the dressing and obtain an order for a wound culture. B. Record observations and keep the dressing in place. C. Consider irrigating the wound. D. Increase the frequency of changing the transparent dressing.

A. Remove the dressing and obtain an order for a wound culture. The wound has advanced from a stage I to a stage II ulcer and shows signs of infection. Removal of the dressing is necessary. A wound culture will determine the type of bacteria growing in the wound. It would also be appropriate to consider using a different type of dressing. Irrigation is likely not necessary for a stage II pressure ulcer. (REF: p. 956, 958)

In addition to assessment of the patient's vital signs and neurologic status, what baseline assessment is needed before the patient with an acute head injury is placed on a hypothermia blanket? A. Skin integrity B. Urinary status C. Respiratory status D. Mucous membranes

A. Skin integrity Application of the hypothermia blanket places the patient's skin in contact with a cooling surface. Although a bath blanket is used to prevent direct contact of the skin with the cooling surface, there remains a risk to skin integrity for the tissues most directly in contact with the blanket. Baseline data provide information to help the clinician determine whether the patient's skin is damaged or a pressure ulcer is developing as a result of the hypothermia. (REF: p. 990)

The NAP reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? A. Implement the "as needed" order to irrigate the catheter. B. Assess the catheter and drainage tubing for obvious occlusion. C. Notify the health care provider immediately. D. Assess the vital signs and intake and output record.

B. Assess the catheter and drainage tubing for obvious occlusion. The priority nursing intervention is to ensure that there is not an occlusion in the catheter or drainage tubing.

A post-operative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? A. Increase the rate of the CBI B. Assess the intake and output C. Decrease the rate of the CBI D. Assess vital signs

B. Assess the intake and output An appropriate first action would be to assess the patency of the drainage system. Urine output in the drainage bag should be more than the volume of the irritant solution infused. If the system is not draining urine and irritant, the irritant should be stopped immediately, the catheter may be occluded and the bladder distended.

An initial shock has been delivered by an AED, and the patient's heart rhythm has not converted afterward. What next step should the nurse take? A. Check the carotid pulse for return of a heartbeat. B. Check that the pads are in good contact with the patient's skin. C. Deliver compressions and rescue breaths at a ratio of 2:30 for 2 minutes. D. Step away from the patient to prepare to shock the patient again.

B. Check that the pads are in good contact with the patient's skin. If the pads are loose and are not making good contact with the patient's skin, the shock delivered will be less powerful than intended and may be ineffective. (REF: p. 682 )

Which nursing action has the highest priority for a patient receiving medication via a nasogastric feeding tube? A. Wait 30 to 60 minutes after feeding to reconnect to suctioning. B. Flush with 30 mL of water before and after feedings. C. Change the feeding pump bag and tubing every 24 hours. D. Keep head of bed elevated above 30 degrees for at least 30 to 60 minutes after feeding.

B. Flush with 30 mL of water before and after feedings. Flushing before and after feeding ensures patency of the feeding tube and correct delivery of the medication. Although keeping the head of the bed elevated is an important step in preventing aspiration, the patency of the tube is a higher priority in correct administration of medication through this route. While waiting the correct amount of time before connecting suctioning and changing the bag on an appropriate schedule are important, flushing is a much higher priority. (REF: pp. 503-504)

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though her color is ruddy not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon Monoxide does which of the following: A. Stimulates hyperventilation causing respiratory alkalosis B. Forms a strong bond with hemoglobin thus preventing oxygen binding in the lungs C. Stimulates hypoventilation causing respiratory acidosis D. Causes alveoli to overinflate leading to atelectasis

B. Forms a strong bond with hemoglobin thus preventing oxygen binding in the lungs Carbon monoxide strongly binds to hemoglobin making it unavailable for oxygen binding and transport.

What nursing intervention decreases the risk for catheter associated urinary tract infection (CAUTI)? A. Cleanse the urinary meatus 3-4 times daily with antiseptic solution. B. Hang the urinary drainage bag below the level with the bladder. C. Empty the urinary drainage bag daily. D. Irrigate the urinary catheter with sterile water.

B. Hang the urinary drainage bag below the level with the bladder. Evidenced based interventions shown to decrease the risk for CAUTI include ensuring that there is a free flow of urine from the catheter to the drainage bag.

An older patient needs to have a fecal impaction removed digitally. The nurse should stop the procedure if which patient information is obtained? A. Blood pressure changes from 120/76 to 128/88 B. Heart rate changes from 74 to 58 C. Heart rate changes from 82 to 96 D. Blood pressure changes from 114/78 to 206/70

B. Heart rate changes from 74 to 58 Stimulation of the vagus nerve can cause bradycardia. The patient must have vital signs obtained as a baseline before the procedure is begun. (REF: p. 849)

There is no urine when a catheter is inserted into a female's urethra. What should the nurse do next? A. Remove the catheter and start all over with a new kit and catheter. B. Leave the catheter there and start over with a new catheter. C. Pull the catheter back and re-insert at a different angle. D. Ask the patient to bear down and insert the catheter further.

B. Leave the catheter there and start over with a new catheter. The catheter may be in the vagina, leave the catheter in the vagina as landmark indicating where not to insert, and insert another sterile catheter. Pulling the catheter back and re-inserting is poor technique increasing the risk for CAUTI.

An immobilized patient has a history of constipation and takes a stool softener at home. Which breakfast selection would be best? A. Banana, donut, rice cereal with milk B. Mixed fruit, oatmeal, whole wheat toast C. Pancakes with syrup, bacon strips, apple juice D. Scrambled eggs, bagel with jelly, orange juice

B. Mixed fruit, oatmeal, whole wheat toast Foods that promote peristalsis are needed; these include high-fiber foods such as raw fruit, whole grains, and green leafy vegetables. (REF: p. 843)

Which of the following skills can safely be delegated routinely to an NAP? A. Tracheostomy care B. Oropharyngeal suctioning C. Airway suctioning using a closed method D. Endotracheal tube care

B. Oropharyngeal suctioning Although an NAP may routinely handle oropharyngeal suctioning, the other skills require the training and judgment of an RN. The nurse is responsible for cardiopulmonary assessment and evaluation of the patient during the skill performance. Only in cases of a permanent tracheostomy or a well-established artificial airway in a stable patient may the skill of suctioning be delegated to an NAP. (REF: pp. 626, 630, 639, 645)

A patient is to be placed on a ventilator. Which nursing action has been found to be most effective in reducing ventilator-associated pneumonia? A. Repositioning the patient every 2 to 3 hours B. Performing mouth care at least four times a day C. Assessing lung sounds every shift D. Performing range-of-motion exercises three times a day

B. Performing mouth care at least four times a day Studies have shown that frequent mouth care decreases the incidence of ventilator-associated pneumonia. The other procedures are important to do, but they do not affect the incidence of ventilator-associated pneumonia. (REF: p. 609 )

The nurse is meeting resistance from the patient during insertion of an oral airway. Which is the most appropriate nursing action given the findings of the patient assessment? A. Obtain assistance from another staff member. B. Reassess the need for oral airway insertion. C. Place the patient on his side during the insertion. D. Notify the physician that the patient needs to be restrained.

B. Reassess the need for oral airway insertion. If the patient is fighting insertion of an oral airway, this is an indication that the patient may be able to maintain his own airway, and that intubation with an oral airway may not be necessary. (REF: p. 679)

The nurse is ready to administer a patient's morning medication when the patient states, "Please leave the medication on my table. I will take it after I use the restroom." Which is the most appropriate response from the nurse? A. "That's fine, please take it the minute you get back from the restroom. I will be back to check on you." B. "It will take only a minute to swallow the medication before you go to the bathroom." C. "I will bring the medication back to your room once you return from the bathroom." D. "I will wait until noon, when you have more medication ordered, and will bring it back to you then."

C. "I will bring the medication back to your room once you return from the bathroom." The nurse should remain with the patient as the patient takes the medication. It is not acceptable to leave medication at the bedside unless a prescriber order to do so has been received. (REF: p. 488)

Collected blood never remains in the chest drain or the ATS blood bag for longer than how many hours before autotransfusion? A. 4 hours B. 8 hours C. 6 hours D. 10 hours

C. 6 hours Collected blood never remains in the chest drain or the ATS blood bag for longer than 6 hours before autotransfusion. (REF: p. 671)

What is a critical step when inserting an indwelling catheter into a male patient? A. Slowly inflate the catheter balloon with sterile saline. B. Secure the catheter drainage tubing to the bed sheets C. Advance the catheter to the bifurcation of the drainage and balloon ports. D. Advance the catheter until urine flows, then insert ¼ inch more.

C. Advance the catheter to the bifurcation of the drainage and balloon ports. Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic urethra causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter drainage tubing to the bed sheets increases the risk for accidental pulling or tension on the catheter. The advancement of the catheter until flows and then inserting ¼ inch more is not unique to the male patient.

Before discharge, the nurse designs a patient teaching plan to help the patient and family correctly perform chest physiotherapy. Why is this teaching an important aspect of patient safety? A. Decreases anxiety of the family caregiver B. Decreases the amount of medical equipment needed in the home care setting C. Because patients and families need to know changes or effects associated with chest PT and when to notify the health care provider D. Reduces readmission to a health care facility

C. Because patients and families need to know changes or effects associated with chest PT and when to notify the health care provider The patient and the caregiver need to know and recognize changes in the patient's respiratory or physiologic status to determine the effectiveness of therapy and to know when they should inform the health care provider of the need for additional therapy. (Ref: p. 619)

A new mother who had a vaginal birth is going to have a sitz bath. In addition to assessing her comfort level, you obtain vital signs. What is the best rationale for obtaining the vital signs? A. Monitoring pain levels B. Monitoring impact of vasoconstriction from the sitz bath C. Providing a baseline for response to therapy D. Documenting circulatory fluid volume

C. Providing a baseline for response to therapy A sitz bath causes vasodilation and the person's blood pressure may drop during the treatment. Obtaining vital signs before the bath provides a baseline in case a change in blood pressure occurs. Although pain affects vital signs, the change in vital signs does not monitor the pain level. Sitz baths cause vasodilation, not constriction, which occurs during cold application. (REF: pp. 980, 982)

What instructions should the nurse give the NAP concerning a patient who has had an indwelling urinary catheter removed that day? A. Limit oral fluid intake to avoid possible urinary incontinence. B. Expect patient complaints of suprapubic fullness and discomfort. C. Report the time and amount of first voiding. D. Instruct patient to stay in bed and use a urinal or bedpan.

C. Report the time and amount of first voiding. In order to adequately assess bladder function after a catheter is removed; voiding frequency and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a UTI.

The low-pressure alarm has sounded on a patient's ventilator. The nurse should check for which of the following situations? A. The patient coughed during the inspiratory cycle. B. The patient is biting on the endotracheal tube. C. The ventilator circuit has a leak. D. The airway needs suctioning.

C. The ventilator circuit has a leak. The two most common causes for the low-pressure alarm sounding (indicating a sudden drop in pressure) are a leak in the ventilate circuit or the patient tube becoming disconnected from the ventilator. Patient coughing or biting on the ET tube may cause the high pressure alarm to sound. Secretions building up in the airway may cause a decrease in the pressure but not a sudden drop. Suctioning is the correct way to address that situation when identified. (REF: p. 606, 610)

The client returns home from a lengthy hospital stay and finds that his family has rearranged the entire first floor of his home, moving his bedroom into the living room. The client reacts with anger toward the family, and the family is confused by his response. Which of the following statements should the nurse make to assist in dealing with this situation? A. To the family, "Didn't I tell you that your father would be unhappy with what you did?" B. (Whispering) To the family, "Don't worry, he will get used to the changes." C. To the client, "Tell me what it is about the changes that make you unhappy." D. To the client, "This new arrangement is much safer for you, so we need to keep it this way."

C. To the client, "Tell me what it is about the changes that make you unhappy." Responding with "Tell me what it is about the changes that make you unhappy" acknowledges the client's distress and gives him an opening to verbalize concerns. Modifications to the home environment should be made only after consultation with the client and evaluation of his strengths and weaknesses. Making changes without his input may have taken away his sense of independence and autonomy. As the nurse, you must advocate for your client and work with the family. (REF: p. 995)

To reduce the risk of polypharmacy, how should the nurse advise the older patient regarding medications? A. Allow a family member to coordinate all prescriptions. B. Have the prescriber call in all prescriptions to the patient's preferred pharmacy instead of providing written prescriptions to the patient. C. Use one pharmacy to coordinate all medications. D. Never use over-the-counter (OTC) drugs or herbal supplements.

C. Use one pharmacy to coordinate all medications. Coordinating all medications through one pharmacy may decrease the risk of drug interactions and duplications. Over-the-counter medications and herbal medications may be acceptable as long as the patient checks with the prescriber or the pharmacist. Family members may not understand the issues around polypharmacy and may not necessarily coordinate prescriptions through one pharmacy; also, enlisting the help of a family member takes away patient autonomy. Asking prescribers to call in all prescriptions does not ensure that a single pharmacy will be used and takes away patient autonomy. (REF: p. 487)

Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? A. Leave a gap of 3-5 inches between the tip of the penis and drainage tube B. Shave the pubic area so that hair does not adhere C. Wash with soap and water prior to applying the condom type catheter. D. Apply tape to the condom sheath to keep it securely in place.

C. Wash with soap and water prior to applying the condom type catheter. Hygiene minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of space between tip of the glans penis and the end of the catheter. Excess space may cause pooling of urine causing excessive exposure to urine. Shaving the pubic area increases the risk for skin irritation. The condom should be secure but not tight. Application of tape is contraindicated because it could interfere with circulation increasing risk for necrosis of the penis.

A patient has been newly diagnosed with chronic lung disease. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A. "I'll make sure that I rest between activities so I don't get so short of breath." B. "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." C. "If I have trouble breathing at night, I'll use two to three pillows to prop up." D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min." Hypoxia is the drive to breathe in a COPD patient who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min will increase oxygen level which turns off the drive to breathe.

Which of the following describes a hydrocolloid dressing? A. A seaweed derivative that is highly absorptive B. Premoistened gauze placed over a granulating wound C. A debriding enzyme that is used to remove necrotic tissue D. A dressing that forms a gel that interacts with the wound surface

D. A dressing that forms a gel that interacts with the wound surface A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is: A. Palpable, elevated hardened area around a tuberculosis skin testing site. B. Sputum for culture and sensitivity identifies mycobacterium tuberculosis C. Presence of acid fast bacilli in sputum D. Arterial oxygen tension (PaO2) of 95 mmHg

D. Arterial oxygen tension (PaO2) of 95 mmHg A palpable, elevated, hardened area surrounding a tuberculosis skin testing site is indicative of an antigen-antibody reaction and is considered a positive skin test. Sputum for culture and sensitivity noted the presence of an organism and acid fast bacilli. Normal arterial oxygen tension (PaO2) ranges between 95-100 mmHg.

A patient with a large surgical wound that is healing by secondary intention has an order for the wound to be packed with gauze that has been moistened in saline. Which of the following steps in packing a wound is incorrect? A. In the case of a deep wound, wear sterile gloves. B. Cover moist gauze packing with dry sterile gauze. C. Pack the wound gently. D. Avoid placing gauze into the sinus tract or an undermined area of the wound.

D. Avoid placing gauze into the sinus tract or an undermined area of the wound. It is important to be sure that any dead space from sinus tracts, undermining, or tunneling is loosely packed with gauze. Loose packing facilitates wicking of drainage. A dry cover gauze pulls moisture from the wound. It is necessary to wear sterile gloves when packing a deep wound. (REF: p. 946)

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. A stage III pressure ulcer needing the appropriate dressing D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

Which of the following diagnosis is a patient who started smoking in adolescence and continues to smoke for 40 years at this risk for? A. Alcoholism and hypertension B. Obesity and diabetes C. Stress-related illnesses D. Cardiopulmonary disease and lung cancer

D. Cardiopulmonary disease and lung cancer Effects of nicotine on blood vessels and lung tissue have increasing pathological effects on the cardiovascular and pulmonary systems.

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? A. Necrotic tissue B. Wound drainage C. Wound circumference D. Cleansed wound

D. Cleansed wound Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

An unconscious patient with a head injury has an oral airway that has been taped in place for several days. Which assessment information obtained by the nurse is most critical because of the patient's status? A. Status of the patient's oral airway B. Frequency of mouth care with lemon glycerin swabs C. How often the patient is being repositioned D. Condition of the lips and surrounding skin

D. Condition of the lips and surrounding skin The patient is unable to let the nursing staff know whether the lips or the skin around the mouth is hurting. An oral airway can cause significant lip and tongue erosion. Lemon glycerin swabs should not be used because they are drying to mucosal tissues. The other assessments are important but do not relate to the presence of the oral airway. (REF: p. 679)

A patient was originally in the intensive care unit and has been moved out to the general surgery unit. The patient is obese and has an 8-inch abdominal incision. The nurse makes rounds and begins to check the patient's dressing when the patient tells the nurse, "I think I felt something just give way in my belly." The nurse removes the gauze dressing over the incision and sees that the wound has Serosanguineous. What should be her next step? A. Notify the patient's health care provider. B. Instruct the patient to lie on the right side. C. Check the patient's blood pressure and heart rate. D. Cover the wound with gauze moistened in sterile saline.

D. Cover the wound with gauze moistened in sterile saline. The first step is to cover the wound with gauze moistened in saline to protect the wound. The nurse should then have the patient lie still without turning. It is important to monitor vital signs and notify the health care provider. (REF: p. 952)

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness

D. Decreased activity tolerance and increased breathlessness Hypoxia occurs due to decreased circulating blood volume which leads to decreased oxygen to muscles causing fatigue and decreased activity tolerance as well as a feeling of shortness of breath.

Why is it best to administer an enteral tube feeding to an elderly client during the day? A. It will cost less if administered during daytime hours. B. It will be more convenient for the caregiver. C. Enteral feeding equipment is too noisy to use during the night. D. Feeding will increase the need for urination.

D. Feeding will increase the need for urination. Increased urination can occur, and if the feeding is administered at night, the elderly client who feels urgency to urinate is at risk for confusion and falling. (REF: p. 1046)

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? A. Sonorous wheezes in the left lower lung B. Rhonchi mid sternum C. Crackles only in apex of lungs D. Inspiratory crackles in lung bases

D. Inspiratory crackles in lung bases Decreased effective contraction of left side of heart leads to back up of fluid in the lungs increasing hydrostatic pressure and causing pulmonary edema.

Which task would be most appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? A. Calling the pharmacy to clarify the correct dose of medication B. Documenting patient's response to medication C. Administering oral medications D. Reporting any changes in patient's status after medication administration

D. Reporting any changes in patient's status after medication administration The NAP has a limited scope of practice; the most appropriate delegation is to have the NAP report changes in the patient's status. (REF: p. 494)

A patient is receiving chest physiotherapy in the home setting. The home health nurse observes the session and notes that the patient is not tolerating the procedure well. Which of the following is the best choice for modifying care? A. Reduce treatments by 2 per day. B. Administer a bronchodilator therapy. C. Let the patient select when treatment is given. D. Suggest using an Acapella device.

D. Suggest using an Acapella device. An Acapella device in conjunction with CPT maneuvers provides airway vibration and assists in clearing the airways. Reducing treatment sessions at all is not acceptable because the patient needs the therapy. The nurse may shorten the session if the patient is able to clear the airway with a shorter session. Administering a bronchodilator requires an order from the health care provider; this would take some time, and the nurse can institute other therapies. Letting the patient select when to have CPT therapy may not be appropriate in that these therapies may have to be scheduled at specific time periods. (REF: p. 620)

Pressure Ulcer: Category/ stage 3:

Full thickness skin loss, subcutaneous fat may be visible. May include undermining

Pressure Ulcer: Category/ stage 4

Full thickness tissue loss, muscle and bone visible. May include undermining.

Pressure Ulcer: Category/ stage 1

Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present.

Pressure Ulcer: Category/ stage 2

Partial thickness skin loss or intact blister with serosanginous fluid.